Plate 139

Although antrectomy with gastrojejunostomy is the usual technique for reconstruction, some preserve the entire stomach and pylorus plus several centimeters of duodenal bulb for end-to-side anastomosis to the jejunal limb according to the method of Longmire. In the usual reconstruction, however, better exposure is obtained for the subsequent steps of the procedure if the stomach is divided at a level that ensures complete removal of the antrum (Figure 7). Truncal vagotomy also is performed to decrease the incidence of late postoperative gastrojejunal stomal ulceration, unless lifetime treatment with proton pump inhibitors or other acid suppressing medication is determined to be preferable.

The spleen is freed up and all gastrosplenic vessels are divided and ligated. The spleen and left half of the pancreas are reflected to the right, providing good exposure for maximal ligation and division of the splenic artery and vein at their origins (Figure 8). Any arterial branches to the superior mesenteric artery are carefully isolated and ligated (Figure 9). The most difficult part of the procedure may be the isolation and ligation of the several short veins entering between the portal vein and the pancreas (Figure 10). The ligated right gastric artery and the pancreaticoduodenal artery are shown in Figure 10.

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